Health Brigade Ryan White Referral Form
This form is HIPAA compliant. You must send all required documentation along with the referral form to submit. The form will not let you submit without everything we need to process your referral. The referral is then sent through our approval process. If it is approved it can take up to two weeks for payment to be issued.
Section A: Type of Referral
EFA only: You have a client at your agency who needs a one time rental/utility/hotel stay and are requesting payment assistance from Health Brigade. Full Client Referral: You have a client who does not currently have a RW case manager in the Richmond area who needs our full scope of services.
Type of Referring Agency
*
Ryan White provider
HOPWA provider
Other
Type of Referral
*
EFA only
Full Client Referral
Section B: Client's General Information
Date of Application
*
-
Month
-
Day
Year
Date
Client's Full Name
*
First Name
Last Name
Client's Phone Number
-
Area Code
Phone Number
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Client's Social Security Number
*
Client's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Section C: Financial Request Information
Applicant name must be on the lease or bill when requesting assistance.
Please select the type of assistance needed and amount due:
*
Rent
Pay or Quit Notice
Utility
7-Day Emergency Hotel Stay
Amount of Request
*
Description of client's need for EFA
*
Please be sure to include information about how Health Brigade is payer of last resort for Ryan White, this includes description of client need. For example: loss of income, illness, etc. Please be as descriptive as possible.
Where else has the client received financial assistance from regarding the current request (ie: Nationz, CAHN, HOPWA, Social Services, Housing Crisis, Commonwealth Catholic Charities, etc.)
*
HB does not long term housing support. Please include details of the housing plan you have been working on with your client:
*
Rental Assistance Information
Name of Landlord/Rental Agency
*
Phone Number of Landlord/Rental Agency
*
-
Area Code
Phone Number
Rental Agency Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Lease Agreement
*
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We require a lease agreement with the client's name, address of the rental unit and signature
Cancel
of
Utility Assistance Information
Utility Company
*
Utility Account Number
*
Utility Bill
*
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We require a copy of the bill with the client's name on it
Cancel
of
Section D: Status Verification + Eligibility Docs
Consent to Share Information/ROI
*
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Cancel
of
Six Month Verification Due Date
*
-
Month
-
Day
Year
Date
HIV Diagnosis Verification
*
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Accepted documentation: Lab test (viral load, CD4, etc) sent from lab or physician or some other documentation submitted from the healthcare provider who is providing medical care verifying status
Cancel
of
Identity Verification
*
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Accepted documents. Must be unexpired: Virginia Driver's License, Tribal ID, Virginia State ID card, Military ID, Passport, Student ID. Social Security Card, Citizenship/Naturalization, Student Visa, Birth Certificate, Virginia Learner's Permit/Temporary license
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of
Residency Verification
*
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One of the following: Unexpired Virginia Driver's License, Unexpired Tribal ID (current address), Unexpired Virginia State ID, Utility Bill (cell phone bill not accepted), Lease, rental or mortgage agreement, Current proprety tax document. OR Two of the following: current Virginia voter registration card (current address), letter from lease holding roommate, copy of public assistance/benefits document, court corrections proof of identity, Homeowner's Association, Military/Veteran's affairs, Virginia vehicle title or registration card
Cancel
of
Proof of Income
*
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Work Income requires 2 months current, consecutive paystubs. Current SSI/SSDI award letter. TANF award letter.
Cancel
of
Section E: Referring Agency Information
Name of Referring Agency
*
Name of Referring case manager or clinician
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Fax Number
*
-
Area Code
Phone Number
Referring Staff Signature
*
Clear
Submit
Should be Empty: